9510-004 (SFD)y LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professionals Code, and my
'License is in full force and effect.
License # s°1 C J f. Lic. Class Exp. Date 11 %1 esfrec"
Dater , E3°C Sig`natureof Contractor ., - / h
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason:
() I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as 'owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals Code).
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of, perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for, workers'.
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is. issued.
(pe I have and will maintain workers' compensation insurance, as required by
SeEtion 3700 of the Labor Code, for the performance of the work for which this
permit is Issued'.ANlyy uVorkers' compensation insuranc,arcarrie_r,f&,policy no. are:
Carrier Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
O I certify that in the performance of the .work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become.
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant
- Warning: Failure to secure Workers' Compensation coverage is unlawful and shall
1 subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT 'Application is hereby made to the Director of Building and Safety
9 for a permit subject to the conditions and restrictions set forth on his application.
1. Each person upon -whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this application agrees to, & shall, ,indemnify
& hold harmless the City of Indian Wells, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
1 certify that I have read this application. and state thatsthe above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of -.this City to enter upon the
above-mentioned property for inspection purposes.
+� y
Signature (Owner/Agent] , , a' /IfC/1/J : r�7 Date
"`C'
BUILDING PERMIT
PERMT•ysac>�xl�
DATE f[a
7
VALUATION $157,LOT
f
_lam
TRACT
2,6352
JOB SITE ADDRESS
APN
3'7_?11`1A17 !'lillw-'n
igA3_14,0.JI&I
OWNER
CONTRACTOR
a
LANDAU DEVELOPMENT
IMPERIAL SUN CONSTRUCTION
47-2)0 v6a OViETU
?525 "IAI1C)Url'Z CANYON #DI.
PAI,M SPR,:INGS CA. 92253
PALM SPRYNGS
CA .92253
a•rnPC T 7� f4
nn�ra
DESIGNER/ENGINEER
(u19327-1476
USE OF PERMIT
S11i)
LAKEY� 1 ((ip�+e ,1
l..f"t.: aE LA. QUINTA A
,.
P' IMIT 1 OEaS NOT 1NC.LUME BLOCI•:. WALLS Ott POOL.
FEE DESCRIPTION
FEES
PLAN CHECK DEPOSIT
42.50.00
,P:4-uA.N CHECK. K18
10 -0*01-439-M
1kC1,S
CONS1'KUMO ' HE
10:1.0004,13-0Cf3
MECMKICAL PEE
101000-421-000
ELEC IWCA1..HE
101-000-420-000
$176.45
!'i.(,jvMi-lW'FFj:
.101 _Q0 -dl -000
NRCh-15i
100-000,241-000S1
S�I:S.iS
GRADING E
,
101-00-423000
xz0.c�o
fNF tAS'1'KliG1U.REFdE
2254000.443-343
$3,454,54
701C.*4)0-755-0M
TOTAL P WW6..e E:f�`ES
$5,419.33
0
T 0 4 1995 oe
BY
RECEIPT
Il -
DATE
I
BY
DATE RNALED
I
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
p
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing 3 //
6
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
S
Drywall - Int. Lath
(�
Final
Final
D G
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances -
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
DESERT SANDS UNIFIED SCHOOL DISTRICT
82=879 Highway 111
.NOTICE: Indio, CA 92201
Document Cannot Be Duplicated 619-775-3500
Date 10/3/95 Type of Permit La Quinta
No. 13737 Permit #
Log.
Owner. Name Landau Development
No. 47210 Street Via Ovieto
City La Quinta Zip 92253 Study Area 123
APN # 643-160-040 Tract # 126152 Lot # 166 Square Footage 12583
Type of Development ISingle Family Residence ' No. of units
Comments
At the present time, the Desert Sands Unified School District does not collect fees on
garages/carports, covered patios/walkways, residential.additions under 500 square feet,
detached accessory structures, or replacement mobilehomes. It has been determined
the above-named owner is exempt from paying school fees at this time due to the
following reason:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080
in the amount of 1.72 x 2"583 or $ 4,442.76 have been paid to D.S.U.S.D. for
the property listed above and that building permits and/or Certificates of Occupancy for
this square footage in this proposed project may now be issued.
Fees Paid:By Imperial- Sun Construction, Inc. T
Name on. the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson
Signature �i ,, Q aM n A A l n k A,4,n,
Payment
$4,442.76 Check No. 14172
Collector: Attach.a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building Dept. /Applicant Copy - Applicant/Receipt Copy - Accounting